Inpatient DRG Reviewer

At Zelis, we Get Stuff Done. So, let's get to it!A Little About UsZelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.A Little About YouYou bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.Position OverviewAs part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for clients.What you will do:Perform comprehensive inpatient DRG validation reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.Perform readmission reviews, including evaluating prior and current admissions to determine preventability, relatedness, and compliance with readmission policies.Based on the evidence presented in the medical records, determine, and record the appropriate (revised) Diagnosis Codes, Procedure Codes and Discharge Status Code applicable to the claim.Using the revised codes, regroup the claim using provided software to determine the 'new DRG' Where the regrouped 'new DRG' differs from what was originally claimed by the provider, write a customer facing 'rationale' or 'findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the reviewDocument all aspects of audits including uploading all provider communications, clinical rationale, and/or financial researchIdentify new DRG coding concepts to expand the DRG product.Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating ProceduresMeet and/or exceed all internal and department productivity and quality standardsRecommend new methods to improve departmental proceduresAchieve and maintain personal production and savings quotaMaintain awareness of and ensure adherence to Zelis standards regarding privacyWhat you will bring:RN or LVN requiredInpatient Coding Certification required (CCS, CIC) within 4 - 6 months of hire date1 -3 years reviewing and or auditing ICD-10 CM, MS-DRG and APPR-DRG claims preferredExperience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programsExperience performing readmission reviews, including evaluating relatedness, preventability, and compliance with readmission policiesUnderstanding of hospital coding and billing rulesClinical skills to evaluate appropriate Medical Record CodingExperience conducting root cause analysis and identifying solutionsStrong organization skills with attention to detailOutstanding verbal and written communication skillsPlease note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.Location and Workplace FlexibilityWe have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.Base Salary Range$79,000.00 - $99,750.00At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.Accessibility SupportWe are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email .DisclaimerThe above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.